A nurse is caring for a client who gave birth 2 hr ago.
The nurse notes that the client's blood pressure is 60/50 mm Hg. Which of the following actions should the nurse take first?.
Evaluate the firmness of the uterus (fundus).
Obtain a type and crossmatch.
Administer oxytocin infusion.
Initiate oxygen therapy by nonrebreather mask.
The Correct Answer is A
The correct answer is choice A.
Choice A rationale:
Evaluating the firmness of the uterus (fundus) is the first action the nurse should take when a client’s blood pressure drops postpartum. A soft or “boggy” uterus can indicate uterine atony, a leading cause of postpartum hemorrhage, which can lead to hypotension.
Choice B rationale:
Obtaining a type and crossmatch is important if the client needs a blood transfusion, but it is not the first action the nurse should take.
Choice C rationale:
Administering oxytocin infusion can help contract the uterus and control bleeding, but the nurse should first assess the uterus.
Choice D rationale:
Initiating oxygen therapy can help if the client is hypoxic, but the nurse should first assess the uterus.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice D. Chronic alcohol use.
Choice A rationale:
Active herpes simplex infection during pregnancy can lead to neonatal herpes, which is a serious condition, but it does not cause the symptoms described.
Choice B rationale:
Chronic cocaine use during pregnancy can lead to premature birth and low birth weight, but it does not typically result in the specific symptoms described.
Choice C rationale:
Folic acid deficiency during pregnancy can lead to neural tube defects, which can cause a range of symptoms, but not the specific ones described.
Choice D rationale:
Chronic alcohol use during pregnancy can lead to Fetal Alcohol Syndrome, which includes slow growth, cognitive and intellectual deficits, and the facial abnormalities described.
Correct Answer is D
Explanation
The correct answer is choice D.
Choice A rationale:
While antidepressants can be an effective treatment for postpartum depression, it is not the priority action. The priority is to ensure the safety of the mother and the baby.
Choice B rationale:
Reinforcing postpartum and newborn care discharge teaching is important, but it is not the priority action when a client is showing signs of postpartum depression.
Choice C rationale:
Assisting the family to identify prior use of positive coping skills in family crises can be helpful, but it is not the priority action when a client is showing signs of postpartum depression.
Choice D rationale:
The priority action when a client is showing signs of postpartum depression is to assess for suicidal ideation or thoughts of harming herself or her baby. This is because postpartum depression can lead to thoughts of self-harm or harm to the baby, and immediate intervention is necessary to ensure the safety of both the mother and the baby.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.